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We describe our experience with perforator-based anterolateral thigh (ALT) flaps for facial contour augmentations in a standardized two-step procedure. In a series of eight consecutive patients (two men, six women) suffering from contour deformities due to different reasons (scleroderma: three, Parry-Romberg syndrome: three, trauma: one, tumor: one), soft tissue augmentations were performed via a preauricular approach. Flaps were harvested from the ALT as perforator-based dermofat (two) or adipofascial flaps (six) with only a small sheet of fascia and a minimal cuff of muscle around the perforators. All flaps were anastomosed to the superficial temporal vessels. For refinement of the primary result, excess volume was removed and minor contour irregularities were smoothed out after 6 months. Despite the small-vessel caliber, anastomoses caused no problems, and all flaps healed well. Because defects were located close to the temporal vessels, the length of the perforator pedicle was always sufficient. Facial contour could further be improved after secondary reshaping of the healed flaps. This led to nearly perfect long-term facial symmetry in all cases. The ALT proved to be a reliable donor site, providing enough well-vascularized fatty tissue for facial contour augmentation in normal-weight patients. No submandibular incision is necessary if the perforators are anastomosed to the superficial temporal vessels. The preauricular incision gives an excellent view to the operating field.